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Secondary Containment Testing Report Form <br /> This form is intended for we by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency, <br /> FACILITY INFORMATION <br /> Facility Narne:_. ,L_,eric, Date of Testing:!S <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989 <br /> Name of Local Agency Inspector(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Chris Graham I.C.C.452510-2-UT <br /> Credentials. N CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A,B,Ha7_,CIO License Number: 312844 <br /> ManufacturgElujaing <br /> Manufacturer Component(s) Date Training i.nires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not —Rep—airs Notes: <br /> Tested Made <br /> Tank Annular <br /> -Secondary Pipe - % or 0 D 9 V40?V*EAZV VOW %N--K TO VSL- WCO <br /> Turbine Sump <br /> UDC <br /> Fill Sump <br /> TI M Sump D D 0 <br /> ❑ D, 0 D <br /> Spill Bucket - 0 0 D El <br /> 0 0 n El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in fall compliance with legal requirements <br /> Technician's Signature: Date:?--. <br />